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Vaismoradi M, Jamshed S, Lorenzl S, Paal P. PRN Medicines Management for Older People with Long-Term Mental Health Disorders in Home Care. Risk Manag Healthc Policy 2021; 14:2841-2849. [PMID: 34262371 PMCID: PMC8274703 DOI: 10.2147/rmhp.s316744] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/02/2021] [Indexed: 12/21/2022] Open
Abstract
Older people with long-term mental health conditions who receive care in their own home are vulnerable to the inappropriate use of medications and polypharmacy given their underlying health conditions and comorbidities. Inappropriate use of pro re nata (PRN) medications in these older people can enhance their suffering and have negative consequences for their quality of life and well-being, leading to readmission to healthcare settings and the increased cost of health care. This narrative review on published international literature aims at improving our understanding of medicines management in home care and how to improve PRN medication use among older people with long-term health conditions in their own home. Accordingly, the improvement of PRN medicines management for these older people requires the development of an individualised care plan considering ‘reduction of older people’s dependence on PRN medications’, ‘empowerment of family caregivers’, and ‘support by healthcare professionals.’ PRN medication use should be reduced through deprescription and discontinuation strategies. Also, older people and their family caregivers should be encouraged to prioritize the use of non-pharmacologic methods to relieve physical and psychological problems. Besides the empowerment of family caregivers through role development, education and training about PRN medications, and involvement in decision-making, they need support by the multidisciplinary network in terms of supervision, monitoring, and home visits.
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Affiliation(s)
- Mojtaba Vaismoradi
- Faculty of Nursing and Health Sciences, Nord University, Bodø, 8049, Norway
| | - Shazia Jamshed
- Clinical Pharmacy and Practice, Faculty of Pharmacy, University Sultan Zainal Abidin, Terengganu, 22200, Malaysia
| | - Stefan Lorenzl
- Professorship for Palliative Care, Institute of Nursing Science and -Practice, Paracelsus Medical University, Salzburg, 5020, Austria.,Department of Neurology, Klinikum Agatharied, Hausham, 83734, Germany
| | - Piret Paal
- WHO Collaborating Centre at the Institute for Nursing Science and Practice, Paracelsus Medical University, Salzburg, A-5020, Austria
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Hospital initiation of benzodiazepines and Z-drugs in older adults and discontinuation in primary care. Res Social Adm Pharm 2021; 18:2670-2674. [PMID: 34127403 DOI: 10.1016/j.sapharm.2021.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 05/28/2021] [Accepted: 06/02/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To examine factors associated with continuation of hospital-initiated benzodiazepine receptor agonists (BZRAs) among adults aged ≥65 years, specifically instructions on hospital discharge summaries. METHODS This retrospective cohort study involved anonymised electronic record data on prescribing and hospitalisations for 38,229 patients aged ≥65 from forty-four GP practices in Ireland 2011-2016. BZRA initiations were identified among patients with no BZRA prescription in the previous 12 months. Multivariate regression examined whether instructions on discharge messages for hospital-initiated BZRA prescriptions was associated with continuation after discharge in primary care and time to discontinuation. RESULTS In total, 418 hospital-initiated BZRAs were identified, 48.8% being to males and mean patient age was 79.0 (SD 8.3) years. Almost 60% of these discharge summarieshad some BZRA instructions (e.g. duration). Approximately 40% (n = 166) were continued in primary care. Lower age, being prescribed a Z-drug or great number of medicines were associated with higher risk of continuation. Of those continued in primary care, in 98 cases (59.6%) the BZRA was discontinued during follow-up (after a mean 184 days). Presence of instructions was associated with higher likelihood of discontinuation (hazard ratio 1.71, 95%CI 1.11-2.62). CONCLUSIONS Improved communication to GPs after hospital discharge may be important in avoiding long-term BZRA use.
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Renom-Guiteras A. Potentially inappropriate medication among people with dementia: towards individualized decision-making. Eur Geriatr Med 2021; 12:569-575. [PMID: 34003481 DOI: 10.1007/s41999-021-00502-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 04/15/2021] [Indexed: 12/18/2022]
Abstract
AIM The aims of this manuscript are to report on several aspects that may deserve special consideration when individualizing decisions on the prescription appropriateness among people with dementia, and to discuss current research needs in relation to these aspects. METHODS Review article based on selective literature. RESULTS The aspects that may deserve special consideration are: the prescription of pychotropic medications, for being commonly inappropriately prescribed; the presence of advanced stage of dementia, comorbidities or multi-morbidity and/or frailty, as they can determine the prognosis and goals of care; the values and wishes of the person with dementia, as they may prioritize different goals of care; and medication adherence, as it may be poorer compared with persons without dementia. Further research on these aspects including representative participants is necessary as evidence base to guide clinical practice. CONCLUSION Individualised decisions on prescription appropriateness among people with dementia may require a comprehensive evaluation of the person in order to establish a shared care plan. Further research will probably support this process.
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Affiliation(s)
- Anna Renom-Guiteras
- Department of Geriatric Medicine. Parc de Salut Mar, Barcelona, Spain. .,Health Services Research on Chronic Patients Network (REDISSEC), Madrid, Spain.
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54
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Hernández-Rodríguez MÁ, Sempere-Verdú E, Vicens-Caldentey C, González-Rubio F, Miguel-García F, Palop-Larrea V, Orueta-Sánchez R, Esteban-Jiménez Ó, Sempere-Manuel M, Arroyo-Aniés MP, Fernández-San José B, de Juan-Roldán JI, Ioakeim-Skoufa I. Drug Prescription Profiles in Patients with Polypharmacy in Spain: A Large-Scale Pharmacoepidemiologic Study Using Real-World Data. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18094754. [PMID: 33946914 PMCID: PMC8125508 DOI: 10.3390/ijerph18094754] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 04/22/2021] [Accepted: 04/26/2021] [Indexed: 12/14/2022]
Abstract
We aimed to identify and compare medication profiles in populations with polypharmacy between 2005 and 2015. We conducted a cross-sectional study using information from the Computerized Database for Pharmacoepidemiologic Studies in Primary Care (BIFAP, Spain). We estimated the prevalence of therapeutic subgroups in all individuals 15 years of age and older with polypharmacy (≥5 drugs during ≥6 months) using the Anatomical Therapeutic Chemical classification system level 4, by sex and age group, for both calendar years. The most prescribed drugs were proton-pump inhibitors (PPIs), statins, antiplatelet agents, benzodiazepine derivatives, and angiotensin-converting enzyme inhibitors. The greatest increases between 2005 and 2015 were observed in PPIs, statins, other antidepressants, and β-blockers, while the prevalence of antiepileptics was almost tripled. We observed increases in psychotropic drugs in women and cardiovascular medications in men. By patient´s age groups, there were notable increases in antipsychotics, antidepressants, and antiepileptics (15–44 years); antidepressants, PPIs, and selective β-blockers (45–64 years); selective β-blockers, biguanides, PPIs, and statins (65–79 years); and in statins, selective β-blockers, and PPIs (80 years and older). Our results revealed important increases in the use of specific therapeutic subgroups, like PPIs, statins, and psychotropic drugs, highlighting opportunities to design and implement strategies to analyze such prescriptions’ appropriateness.
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Affiliation(s)
- Miguel Ángel Hernández-Rodríguez
- Drug Utilization Work Group, Spanish Society of Family and Community Medicine (semFYC), ES-08009 Barcelona, Spain; (E.S.-V.); (C.V.-C.); (F.G.-R.); (F.M.-G.); (V.P.-L.); (R.O.-S.); (Ó.E.-J.); (M.S.-M.); (M.P.A.-A.); (B.F.-S.J.); (J.I.d.J.-R.)
- Dirección del Servicio Canario de la Salud, Plan de Salud de Canarias, ES-38004 Santa Cruz de Tenerife, Spain
- Correspondence: (M.Á.H.-R.); (I.I.-S.)
| | - Ermengol Sempere-Verdú
- Drug Utilization Work Group, Spanish Society of Family and Community Medicine (semFYC), ES-08009 Barcelona, Spain; (E.S.-V.); (C.V.-C.); (F.G.-R.); (F.M.-G.); (V.P.-L.); (R.O.-S.); (Ó.E.-J.); (M.S.-M.); (M.P.A.-A.); (B.F.-S.J.); (J.I.d.J.-R.)
- Centro de Salud de Paterna, Conselleria de Sanitat Universal i Salut Pública, Generalitat Valenciana, ES-46980 Valencia, Spain
| | - Caterina Vicens-Caldentey
- Drug Utilization Work Group, Spanish Society of Family and Community Medicine (semFYC), ES-08009 Barcelona, Spain; (E.S.-V.); (C.V.-C.); (F.G.-R.); (F.M.-G.); (V.P.-L.); (R.O.-S.); (Ó.E.-J.); (M.S.-M.); (M.P.A.-A.); (B.F.-S.J.); (J.I.d.J.-R.)
- Centro de Salud Son Serra-La Vileta, Servicio de Salud de las Islas Baleares Ib-salut, ES-07013 Palma, Spain
- Institut d’Investigació Sanitaria Illes Balears (IDISBA), Servicio de Salud de las Islas Baleares Ib-salut, ES-07120 Palma de Mallorca, Spain
| | - Francisca González-Rubio
- Drug Utilization Work Group, Spanish Society of Family and Community Medicine (semFYC), ES-08009 Barcelona, Spain; (E.S.-V.); (C.V.-C.); (F.G.-R.); (F.M.-G.); (V.P.-L.); (R.O.-S.); (Ó.E.-J.); (M.S.-M.); (M.P.A.-A.); (B.F.-S.J.); (J.I.d.J.-R.)
- Centro de Salud Delicias Sur, Servicio Aragonés de Salud, ES-50009 Zaragoza, Spain
- EpiChron Research Group on Chronic Diseases, Aragon Health Research Institute (IIS Aragón), ES-50009 Zaragoza, Spain
| | - Félix Miguel-García
- Drug Utilization Work Group, Spanish Society of Family and Community Medicine (semFYC), ES-08009 Barcelona, Spain; (E.S.-V.); (C.V.-C.); (F.G.-R.); (F.M.-G.); (V.P.-L.); (R.O.-S.); (Ó.E.-J.); (M.S.-M.); (M.P.A.-A.); (B.F.-S.J.); (J.I.d.J.-R.)
- Ministerio de Sanidad, Consumo y Bienestar Social, ES-28014 Madrid, Spain
| | - Vicente Palop-Larrea
- Drug Utilization Work Group, Spanish Society of Family and Community Medicine (semFYC), ES-08009 Barcelona, Spain; (E.S.-V.); (C.V.-C.); (F.G.-R.); (F.M.-G.); (V.P.-L.); (R.O.-S.); (Ó.E.-J.); (M.S.-M.); (M.P.A.-A.); (B.F.-S.J.); (J.I.d.J.-R.)
- Hospital de Denia. Marina Salud, Conselleria de Sanitat Universal i Salut Pública, Generalitat Valenciana, ES-03700 Alicante, Spain
| | - Ramón Orueta-Sánchez
- Drug Utilization Work Group, Spanish Society of Family and Community Medicine (semFYC), ES-08009 Barcelona, Spain; (E.S.-V.); (C.V.-C.); (F.G.-R.); (F.M.-G.); (V.P.-L.); (R.O.-S.); (Ó.E.-J.); (M.S.-M.); (M.P.A.-A.); (B.F.-S.J.); (J.I.d.J.-R.)
- Centro de Salud de Sillería, Servicio de Salud de Castilla-La Mancha, ES-45001 Toledo, Spain
| | - Óscar Esteban-Jiménez
- Drug Utilization Work Group, Spanish Society of Family and Community Medicine (semFYC), ES-08009 Barcelona, Spain; (E.S.-V.); (C.V.-C.); (F.G.-R.); (F.M.-G.); (V.P.-L.); (R.O.-S.); (Ó.E.-J.); (M.S.-M.); (M.P.A.-A.); (B.F.-S.J.); (J.I.d.J.-R.)
- Centro de Salud de Sádaba, Servicio Aragonés de Salud, ES-50670 Zaragoza, Spain
| | - Mara Sempere-Manuel
- Drug Utilization Work Group, Spanish Society of Family and Community Medicine (semFYC), ES-08009 Barcelona, Spain; (E.S.-V.); (C.V.-C.); (F.G.-R.); (F.M.-G.); (V.P.-L.); (R.O.-S.); (Ó.E.-J.); (M.S.-M.); (M.P.A.-A.); (B.F.-S.J.); (J.I.d.J.-R.)
- Centro de Salud de Sueca, Conselleria de Sanitat Universal i Salut Pública, Generalitat Valenciana, ES-46410 Valencia, Spain
| | - María Pilar Arroyo-Aniés
- Drug Utilization Work Group, Spanish Society of Family and Community Medicine (semFYC), ES-08009 Barcelona, Spain; (E.S.-V.); (C.V.-C.); (F.G.-R.); (F.M.-G.); (V.P.-L.); (R.O.-S.); (Ó.E.-J.); (M.S.-M.); (M.P.A.-A.); (B.F.-S.J.); (J.I.d.J.-R.)
- Centro de Salud de Huarte, Servicio Navarro de Salud, ES-31620 Pamplona, Spain
| | - Buenaventura Fernández-San José
- Drug Utilization Work Group, Spanish Society of Family and Community Medicine (semFYC), ES-08009 Barcelona, Spain; (E.S.-V.); (C.V.-C.); (F.G.-R.); (F.M.-G.); (V.P.-L.); (R.O.-S.); (Ó.E.-J.); (M.S.-M.); (M.P.A.-A.); (B.F.-S.J.); (J.I.d.J.-R.)
- Centro de Salud de Canalejas, Servicio Canario de la Salud, ES-35004 Las Palmas de Gran Canaria, Spain
| | - José Ignacio de Juan-Roldán
- Drug Utilization Work Group, Spanish Society of Family and Community Medicine (semFYC), ES-08009 Barcelona, Spain; (E.S.-V.); (C.V.-C.); (F.G.-R.); (F.M.-G.); (V.P.-L.); (R.O.-S.); (Ó.E.-J.); (M.S.-M.); (M.P.A.-A.); (B.F.-S.J.); (J.I.d.J.-R.)
- Departamento de Farmacología y Pediatría, Facultad de Medicina, Universidad de Málaga, ES-29010 Málaga, Spain
| | - Ignatios Ioakeim-Skoufa
- Drug Utilization Work Group, Spanish Society of Family and Community Medicine (semFYC), ES-08009 Barcelona, Spain; (E.S.-V.); (C.V.-C.); (F.G.-R.); (F.M.-G.); (V.P.-L.); (R.O.-S.); (Ó.E.-J.); (M.S.-M.); (M.P.A.-A.); (B.F.-S.J.); (J.I.d.J.-R.)
- EpiChron Research Group on Chronic Diseases, Aragon Health Research Institute (IIS Aragón), ES-50009 Zaragoza, Spain
- Vaksinasjonssenter BSN, Bydel Søndre Nordstrand, Oslo kommune, NO-1252 Oslo, Norway
- Correspondence: (M.Á.H.-R.); (I.I.-S.)
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55
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Williams S, Louissaint J, Nikirk S, Bajaj JS, Tapper EB. Deprescribing medications that may increase the risk of hepatic encephalopathy: A qualitative study of patients with cirrhosis and their doctors. United European Gastroenterol J 2021; 9:193-202. [PMID: 33226300 PMCID: PMC8259255 DOI: 10.1177/2050640620975224] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 10/25/2020] [Indexed: 12/19/2022] Open
Abstract
Background and Aims Multiple medications are associated with an increased risk of incident hepatic encephalopathy. Despite this known risk, medications such as opioids, benzodiazepines, gabapentin/pregabalin, and/or proton pump inhibitors are increasingly prescribed to persons with cirrhosis. Deprescribing is a promising intervention to reduce the burden of hepatic encephalopathy. Given that deprescribing has not been trialed in cirrhosis, we evaluated the barriers and facilitators to safe and successful deprescribing in cirrhosis. Methods We conducted, transcribed, and analyzed semi‐structured interviews using qualitative methodology with 22 subjects. This included eight patients with cirrhosis and recent use of opiates, benzodiazepines, gabapentin/Lyrica, and/or proton pump inhibitors as well as 14 providers (primary care, transplant surgery, transplant hepatology). Interviews explored opinions, behaviors, and understanding surrounding the risks and benefits of deprescribing. Results Major provider‐specific barriers included deferred responsibility of the deprescribing process, knowledge gaps regarding the risk of hepatic encephalopathy associated with medications (e.g., proton pump inhibitors) as well as the safe method of deprescription (i.e., benzodiazepines), and time constraints. Patient‐specific barriers included knowledge gaps regarding the cirrhosis‐specific risks of their medications and anxiety about the recurrence of symptoms after medication discontinuation. Patients uniformly reported trust in their provider's opinions on risks and wished for more comprehensive education during or after visits. Providers uniformly reported support for deprescription resources including pharmacist or nurse outreach. Conclusion Given knowledge of medication risks related to hepatic encephalopathy in patients with cirrhosis, deprescribing is universally seen as important. Knowledge gaps, inaction, and uncertainty regarding feasible alternatives prevent meaningful implementation of deprescription. Trials of protocolized pharmacy‐based deprescribing outreach and patient‐facing education on risks are warranted.
Summarize the established knowledge on this subject
Hepatic encephalopathy (HE) is a morbid complication of cirrhosis. The risk of HE may be increased by psychoactive medications and proton pump inhibitors. Deprescribing is felt to be a promising approach to HE prevention.
What are the significant and/or new findings of this study?
Patients are unaware of how their medications influence the risk of HE. Patients are willing to follow physician recommendations regarding deprescribing but are afraid of worsening symptoms. Physicians do not feel comfortable deprescribing opioids or benzodiazepines. Physicians do not feel responsible or equipped with the resources for deprescribing.
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Affiliation(s)
- Sydni Williams
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Jeremy Louissaint
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Sam Nikirk
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Jasmohan S Bajaj
- Division of Gastroenterology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA.,Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
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Capiau A, Foubert K, Somers A, Petrovic M. Guidance for appropriate use of psychotropic drugs in older people. Eur Geriatr Med 2021; 12:577-583. [PMID: 33417167 DOI: 10.1007/s41999-020-00439-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 12/10/2020] [Indexed: 12/13/2022]
Abstract
Psychotropic drugs are widely prescribed in older people although their use is associated with important risks. In this position paper, we discuss the appropriateness of using these medications in older people in terms of different aspects such as indications, contraindications, dosing, adverse drug reactions, interactions and duration of therapy. Consequently, we discuss different strategies to increase the appropriateness of therapy while formulating some practical recommendations to keep in mind when (de)prescribing psychotropic drugs in older people.
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Affiliation(s)
- Andreas Capiau
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium.
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium.
| | - Katrien Foubert
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Annemie Somers
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Mirko Petrovic
- Department of Geriatrics, Ghent University Hospital, Ghent, Belgium
- Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
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57
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Hoel RW, Giddings Connolly RM, Takahashi PY. Polypharmacy Management in Older Patients. Mayo Clin Proc 2021; 96:242-256. [PMID: 33413822 DOI: 10.1016/j.mayocp.2020.06.012] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 05/18/2020] [Accepted: 06/10/2020] [Indexed: 12/14/2022]
Abstract
Medications to treat disease and extend life in our patients often amass in quantities, resulting in what has been termed "polypharmacy." This imprecise label usually describes the accumulation of 5, and often more, medications. Polypharmacy in advancing age frequently results in drug therapy problems related to interactions, drug toxicity, falls with injury, delirium, and nonadherence. Polypharmacy is associated with resulting increased hospitalizations and higher costs of care for individuals and health care systems. To reduce polypharmacy, we delineate a systematic, consultative approach to identify highest-risk medications and drug-therapy problems. We address strategic reductions (deprescribing) of medications in palliative care, long-term care, and ambulatory older adults. Best practices for reducing opioids, benzodiazepines, and other high-risk medications include education about risk and agreement by patients and their families, advocates, and care teams. Addressing deprescribing should be within the framework of patients' health status as their care and goals transition from longevity to a plan of maintaining alertness, comfort, and satisfaction of quality of life. A team approach to address polypharmacy and avoidance of high-risk therapy is optimal within long-term care. Patients with terminal illnesses or those moving toward a comfort-care emphasis benefit from medication adjustments that are recognized beneficially within each patient's care goals. In caring for older adults, the acknowledgement that complicated regimens and high-risk medications requires a care plan to reduce or prevent medication-related problems and costs that are associated with polypharmacy.
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Affiliation(s)
- Robert William Hoel
- Division of Medication Therapy Management, Pharmacy Services, Mayo Clinic, Rochester, MN.
| | | | - Paul Y Takahashi
- Division of Community Internal Medicine, Mayo Clinic, Rochester, MN
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58
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Pétein C, Spinewine A, Henrard S. Trends in benzodiazepine receptor agonists use and associated factors in the Belgian general older population: analysis of the Belgian health interview survey data. Ther Adv Psychopharmacol 2021; 11:20451253211011874. [PMID: 34104414 PMCID: PMC8161882 DOI: 10.1177/20451253211011874] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 04/01/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Benzodiazepine receptor agonists (BZRA), which include benzodiazepines and z-drugs, are commonly prescribed for insomnia and anxiety in older adults, and used often long term. Yet, the risk-benefit ratio of BZRA use in older adults may be unfavorable and many recommendations suggest avoidance or a maximal treatment duration of 4 weeks. The aim of this study was to describe trends of BZRA use in older adults and associated factors. METHODS Using data from the Belgian Health Interview Survey in 2004 (n = 3594), 2008 (n = 2917), and 2013 (n = 2048), prevalence standardized for age, sex, and region were calculated to assess trends of BZRA use in people ⩾65 years. Analysis of associated factors to BZRA use was performed using a sub-sample of 2013 data for which variables assessing sleeping disorder and anxiety disorder were not missing (n = 1286). Variables from seven main topics were explored using multivariate logistic regression: socio-demographic factors, geriatric factors, comorbidities, subjective health and mental health indicators, social health indicators, medication use and healthcare services use. RESULTS Overall, standardized prevalence of BZRA use decreased significantly between 2004 and 2013 [22% to 18%, prevalence difference (95% confidence interval, CI): -4.0% (-6.8; -1.3)]. Factors associated with BZRA use in multivariable analysis included female gender [adjusted odds ratio (aOR) (95%CI) : 1.62 (1.14; 2.29)], poor mental health [aOR (95%CI): 1.73 (1.13-2.63)] a fall in the past 12 months [aOR (95%CI): 1.52 (1.02; 2.26), reporting a sleeping disorder [aOR (95%CI): 1.92 (1.35; 2.72)], polypharmacy [aOR (95%CI): 2.51 (1.75; 3.60)], and trazodone use [aOR (95%CI): 4.05 (1.64; 10.21)]. CONCLUSION Despite an encouraging decline observed from 2004 to 2013, BZRA use remained highly prevalent in Belgian older adults. Promotion of alternatives to BZRA in treatment of sleeping problems need to be continued. Among BZRA older users, women, the oldest (⩾85 years) and high-risk subgroups should be targeted in deprescribing interventions.
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Affiliation(s)
- Catherine Pétein
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université catholique de Louvain, Avenue Mounier, 72 bte B1.72.02, Brussels, 1200, Belgium
| | - Anne Spinewine
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium
| | - Séverine Henrard
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium
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59
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Pergolizzi JV, LeQuang JA, Raffa RB. Benzodiazepines: Thinking outside the black box. J Clin Pharm Ther 2020; 46:554-559. [PMID: 33347636 DOI: 10.1111/jcpt.13333] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 11/29/2020] [Accepted: 12/03/2020] [Indexed: 12/15/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE The United States Food and Drug Administration (FDA) recently issued a Drug Safety Communication requiring Boxed Warning updating and other changes in order to improve the safe use of the benzodiazepine drug class. These changes were prompted because 'The current prescribing information for benzodiazepines does not provide adequate warnings about [the] serious risks and harms associated with these medicines so they may be prescribed and used inappropriately'. COMMENT The FDA Communication points out that benzodiazepines can be an important option for treating disorders for which these drugs are indicated. However, the acknowledged problems of these drugs, which historically were considered an acceptable trade-off against their benefits, need to be reassessed in light of their widespread (over?) prescribing (for example, in 2019 an estimated 92 million benzodiazepine prescriptions were dispensed from US retail and mail-order pharmacies). WHAT IS NEW AND CONCLUSION The FDA Communication can be viewed as an important step in reminding healthcare providers of the 'serious risks and harms associated with these medicines', and validation of such reports by patients. Importantly, the FDA Communication includes an often-neglected aspect of benzodiazepine prescribing, namely how to discontinue use, and the perplexing protracted withdrawal syndrome experienced by some patients. The Communication advises to providers: 'No standard benzodiazepine tapering schedule is suitable for all patients; therefore, create a patient-specific plan to gradually reduce the dosage, and ensure ongoing monitoring and support as needed to avoid serious withdrawal symptoms or worsening of the patient's medical condition'.
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Affiliation(s)
| | | | - Robert B Raffa
- Neumentum Inc., Summit, NJ, USA.,University of Arizona College of Pharmacy (Adjunct), University of Arizona, Tucson, AZ, USA.,Temple University School of Pharmacy (Emeritus), Philadelphia, PA, USA
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60
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Dooley K, Snodgrass SJ, Stanwell P, Birse S, Schultz A, Drew MK, Edwards S. Spatial muscle activation patterns during different leg exercise protocols in physically active adults using muscle functional MRI: a systematic review. J Appl Physiol (1985) 2020; 129:934-946. [PMID: 32853111 DOI: 10.1152/japplphysiol.00290.2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
An emerging method to measure muscle activation patterns is muscle functional magnetic resonance imaging (mfMRI), where preexercise and postexercise muscle metabolism differences indicate spatial muscle activation patterns. We evaluated studies employing mfMRI to determine activation patterns of lumbar or lower limb muscles following exercise in physically active adults. Electronic systematic searches were conducted until March 2020. All studies employing ≥1.5 Tesla MRI scanners to compare spatial muscle activation patterns at the level of or inferior to the first lumbar vertebra in healthy, active adults. Two authors independently assessed study eligibility before appraising methodological quality using a National Institutes of Health assessment tool. Because of heterogeneity, findings were synthesized without meta-analysis. Of the 1,946 studies identified, seven qualified for inclusion and pertained to hamstring (n = 5), quadriceps (n = 1) or extrinsic foot (n = 1) muscles. All included studies controlled for internal validity, with one employing assessor blinding. MRI physics and differing research questions explain study methodology heterogeneity. Significant mfMRI findings were: following Nordic exercise, hamstrings with previous trauma (strain or surgical autograft harvest) demonstrated reduced activation compared with unharmed contralateral muscles, and asymptomatic individuals preferentially activated semitendinosus; greater biceps femoris long head to semitendinosus ratios reported following 45° hip extension over Nordic exercise; greater rectus femoris activation occurred in "flywheel" over barbell squats. mfMRI parameters differ on the basis of individual research questions. Individual muscles show greater activation following specific exercises, suggesting exercise specificity may be important for rehabilitation, although evidence is limited to single cohort studies comparing interlimb differences preexercise versus postexercise.
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Affiliation(s)
- Katherine Dooley
- School of Health Sciences, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Suzanne J Snodgrass
- School of Health Sciences, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Peter Stanwell
- School of Health Sciences, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Samantha Birse
- School of Environmental and Life Sciences, The University of Newcastle, Ourimbah, New South Wales, Australia
| | - Adrian Schultz
- School of Environmental and Life Sciences, The University of Newcastle, Ourimbah, New South Wales, Australia
| | - Michael K Drew
- Department of Physical Therapies, Australian Institute of Sport, Canberra, Australia
| | - Suzi Edwards
- School of Environmental and Life Sciences, The University of Newcastle, Ourimbah, New South Wales, Australia
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Isenor JE, Bai I, Cormier R, Helwig M, Reeve E, Whelan AM, Burgess S, Martin-Misener R, Kennie-Kaulbach N. Deprescribing interventions in primary health care mapped to the Behaviour Change Wheel: A scoping review. Res Social Adm Pharm 2020; 17:1229-1241. [PMID: 32978088 DOI: 10.1016/j.sapharm.2020.09.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 06/17/2020] [Accepted: 09/07/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Polypharmacy and inappropriate medication use are an increasing concern. Deprescribing may improve medication use through planned and supervised dose reduction or stopping of medications. As most medication management occurs in primary health care, which is generally described as the first point of access for day-to-day care, deprescribing in primary health care is the focus on this review. OBJECTIVE This scoping review aimed to identify and characterize strategies for deprescribing in primary health care and map the strategies to the Behaviour Change Wheel (BCW). METHODS A scoping review was conducted that involved searches of six databases (2002-2018) and reference lists of relevant systematic reviews and included studies. Studies that described and evaluated deprescribing strategies in primary health care were eligible. Two independent reviewers screened articles and completed data charting with charting verified by a third. Deprescribing strategies were mapped to the intervention functions of the BCW and linked to specific Behaviour Change Techniques (BCT). RESULTS Searches yielded 6871 citations of which 43 were included. Nineteen studies were randomized, 24 were non-randomized. Studies evaluated deprescribing in terms of medication changes, feasibility, and prescriber/patient perspectives. Deprescribing strategies involved various professionals (physicians, pharmacists, nurses), as well as patients and were generally multifaceted. A wide range of intervention functions were identified, with 41 BCTs mapped to Environmental restructuring, 38 BCTs mapped to Enablement, and 34 BCTs mapped to Persuasion. CONCLUSIONS Deprescribing strategies in primary health care have used a variety of BCTs to address individual professionals (e.g. education) as well as strategies that addressed the practice setting, including support from additional team members (e.g. pharmacists, nurses and patients). Further research is warranted to determine comparative effectiveness of different BCTs, which can help facilitate implementation of deprescribing strategies, thereby reducing polypharmacy, in primary health care.
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Affiliation(s)
- Jennifer E Isenor
- College of Pharmacy, Dalhousie University, 5968 College Street, Halifax, NS, Canada.
| | - Isaac Bai
- College of Pharmacy, Dalhousie University, 5968 College Street, Halifax, NS, Canada
| | - Rachel Cormier
- College of Pharmacy, Dalhousie University, 5968 College Street, Halifax, NS, Canada
| | - Melissa Helwig
- W.K. Kellogg Health Sciences Library, Dalhousie University, Halifax, NS, Canada
| | - Emily Reeve
- College of Pharmacy, Dalhousie University, 5968 College Street, Halifax, NS, Canada; Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Division of Health Sciences, University of South Australia, Adelaide, SA, Australia; Geriatric Medicine Research, Faculty of Medicine, Dalhousie University and Nova Scotia Health Authority, Halifax, NS, Canada
| | - Anne Marie Whelan
- College of Pharmacy, Dalhousie University, 5968 College Street, Halifax, NS, Canada
| | - Sarah Burgess
- Pharmacy Department, Nova Scotia Health Authority, Halifax, NS, Canada
| | - Ruth Martin-Misener
- School of Nursing, Dalhousie University, 5869 University Avenue, Halifax, NS, Canada
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Abstract
Polypharmacy, the use of five or more medications, is common in older adults. It can lead to the use of potentially inappropriate medications and severe adverse outcomes. Deprescribing is an essential step of the thoughtful prescribing process and it can decrease the use of potentially inappropriate medications. Studies have demonstrated that deprescribing is feasible in the clinical setting, especially when it incorporates patient preferences, shared decision making, and an interdisciplinary team. Medication-specific algorithms can facilitate deprescribing in the clinical setting.
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Affiliation(s)
- Vassiliki Pravodelov
- Section of Geriatrics, Department of Medicine, Boston University School of Medicine, 72 East Concord Street, Robinson 2, Boston, MA 02118, USA; Boston Medical Center, One Boston Medical Center Place, Boston, MA 02118, USA.
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Turner JP, Sanyal C, Martin P, Tannenbaum C. Economic Evaluation of Sedative Deprescribing in Older Adults by Community Pharmacists. J Gerontol A Biol Sci Med Sci 2020; 76:1061-1067. [DOI: 10.1093/gerona/glaa180] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Indexed: 01/30/2023] Open
Abstract
Abstract
Background
Sedative use in older adults increases the risk of falls, fractures, and hospitalizations. The D-PRESCRIBE (Developing Pharmacist-Led Research to Educate and Sensitize Community Residents to the Inappropriate Prescriptions Burden in the Elderly), pragmatic randomized clinical trial demonstrated that community-based, pharmacist-led education delivered simultaneously to older adults and their primary care providers reduce the use of sedatives by 43% over 6 months. However, the associated health benefits and cost savings have yet to be described. This study evaluates the cost-effectiveness of the D-PRESCRIBE intervention compared to usual care for reducing the use of potentially inappropriate sedatives among older adults.
Methods
A cost-utility analysis from the public health care perspective of Canada estimated the costs and quality-adjusted life-years (QALYs) associated with the D-PRESCRIBE intervention compared to usual care over a 1-year time horizon. Transition probabilities, intervention effectiveness, utility, and costs were derived from the literature. Probabilistic analyses were performed using a decision tree and Markov model to estimate the incremental cost-effectiveness ratio.
Results
Compared to usual care, pharmacist-led deprescribing is less costly (−$1392.05 CAD) and more effective (0.0769 QALYs). Using common willingness-to-pay (WTP) thresholds of $50 000 and $100 000, D-PRESCRIBE was the optimal strategy. Scenario analysis indicated the cost-effectiveness of D-PRESCRIBE is sensitive to the rate of deprescribing.
Conclusions
Community pharmacist-led deprescribing of sedatives is cost-effective, leading to greater quality-of-life and harm reduction among older adults. As the pharmacist’s scope of practice expands, consideration should be given to interprofessional models of remuneration for quality prescribing and deprescribing services.
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Affiliation(s)
- Justin P Turner
- Faculty of Pharmacy, Université de Montréal, Québec, Canada
- Centre de Recherche, Institut Universitaire de Gériatrie de Montréal, Québec, Canada
| | | | - Philippe Martin
- Faculty of Pharmacy, Université de Montréal, Québec, Canada
- Centre de Recherche, Institut Universitaire de Gériatrie de Montréal, Québec, Canada
| | - Cara Tannenbaum
- Faculty of Pharmacy, Université de Montréal, Québec, Canada
- Faculty of Medicine, Université de Montréal, Québec, Canada
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Shaw J, Murphy AL, Turner JP, Gardner DM, Silvius JL, Bouck Z, Gordon D, Tannenbaum C. Policies for Deprescribing: An International Scan of Intended and Unintended Outcomes of Limiting Sedative-Hypnotic Use in Community-Dwelling Older Adults. ACTA ACUST UNITED AC 2020; 14:39-51. [PMID: 31322113 PMCID: PMC7008681 DOI: 10.12927/hcpol.2019.25857] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022]
Abstract
Policies have been put in place internationally to reduce the overuse of certain medications that have a high risk of harm, such as sedative-hypnotic drugs for insomnia or opioids for chronic non-cancer pain. We explore and compare the outcomes of policies aimed at deprescribing sedative-hypnotic medication in community-dwelling older adults. Prescription monitoring policies led to the highest rate of discontinuation but triggered inappropriate substitutions. Financial deterrents through insurance scheme delistings increased patient out-of-pocket spending and had minimal impact. Pay-for-performance incentives to prescribers proved ineffective. Rescheduling alprazolam to a controlled substance raised the street drug price of the drug and shifted use to other benzodiazepines, causing similar rates of overdose deaths. Driving safety policies and jurisdiction-wide educational campaigns promoting non-drug alternatives appear most promising for achieving intended outcomes and avoiding unintended harms. Sustainable change should be supported with direct-to-patient education and improved access to non-drug therapy, with an emphasis on evaluating both intended and unintended consequences of any deprescribing-oriented policy.
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Affiliation(s)
- James Shaw
- Assistant Professor, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON
| | - Andrea L Murphy
- Associate Professor, College of Pharmacy, Dalhousie University, Halifax, NS
| | - Justin P Turner
- Graduate Student, Centre de Recherche Institut Universitaire de Gériatrie de Montréal, Montreal, QC
| | - David M Gardner
- Professor, Department of Psychiatry, Dalhousie University, Halifax, NS
| | - James L Silvius
- Co-Director, Canadian Deprescribing Network; Associate Professor, Department of Medicine, University of Calgary, Calgary, AB
| | - Zachary Bouck
- Biostatistician, Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON
| | - Dara Gordon
- Research Coordinator, Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON
| | - Cara Tannenbaum
- Co-Director, Canadian Deprescribing Network; Professor, Faculties of Medicine and Pharmacy Université de Montréal, Montreal, QC
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65
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Wright DJ, Scott S, Buck J, Bhattacharya D. Role of nurses in supporting proactive deprescribing. Nurs Stand 2020; 34:44-50. [PMID: 31468926 DOI: 10.7748/ns.2019.e11249] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2018] [Indexed: 01/15/2023]
Abstract
Deprescribing is the term used to describe the discontinuation of medicines. It can be either 'reactive', for example in response to an adverse event or therapeutic failure, or 'proactive', when the prescriber and patient decide to discontinue the medicine because its future benefits no longer outweigh its potential for harm. At present, there is a limited amount of proactive deprescribing activity in primary and secondary care. This article provides the rationale for increasing proactive deprescribing activity, lists the medicines this relates to, identifies the barriers and enablers to its implementation, and describes the potential role of the nurse in this process.
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Affiliation(s)
| | - Sion Scott
- School of Pharmacy, University of East Anglia, Norwich, England
| | - Jackie Buck
- School of Health Sciences, University of East Anglia, Norwich, England
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Olry de Labry Lima A, Marcos Marcos J, Marquina Marquez A, González Vera MDLÁ, Matas Hoces A, Bermúdez Tamayo C. Evidence for deprescription in primary care through an umbrella review. BMC FAMILY PRACTICE 2020; 21:100. [PMID: 32513110 PMCID: PMC7278115 DOI: 10.1186/s12875-020-01166-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 05/14/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND There is a high prevalence of potentially inappropriate prescriptions in primary care. This is associated with more frequent adverse events, lower quality of life and more frequent visits to hospital accident & emergency departments. The aim of the present study is to summarise available evidence on the effectiveness of deprescription interventions in primary care, and to describe the barriers and enablers of the process from the point of view of patients and healthcare professionals. METHODS We designed an umbrella review which includes nine systematic reviews. More than 50% of included studies were performed with adults in primary care. Two reviewers independently performed data extraction and analysis. RESULTS In considering studies of the effectiveness of interventions, it can be observed that the educational component of deprescription procedures is a key factor, whilst procedures tailored towards the patient's situation offer better results. With regards to studies involving healthcare professionals, the main explored areas were the balance between risks and benefits, and the need to improve communication with patients as well as other colleagues involved in patient care. Amongst the identified barriers we found lack of time, inability to access all information, being stuck in a routine, resistance to change and a lack of willingness to question the prescription decisions made by healthcare colleagues. With regards to patients, it is clear that they have worries and doubts. In order to overcome these issues, a good relationship with healthcare professionals and receipt of their support is required during the process. CONCLUSIONS Optimizing medication through targeted deprescribing is an important part of managing chronic conditions, avoiding adverse effects and improving outcomes. The majority of deprescription interventions in primary care are effective. Good communication between healthcare professionals is a key element for success in the deprescription process.
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Affiliation(s)
- Antonio Olry de Labry Lima
- Andalusian School of Public Health (Spanish acronym EASP), Granada, Spain. .,Instituto de Investigación Biosanitaria ibs, GRANADA, Granada, Spain. .,CIBER en Epidemiología and Salud Pública (CIBERESP), Madrid, Spain.
| | - Jorge Marcos Marcos
- Andalusian School of Public Health (Spanish acronym EASP), Granada, Spain.,Public Health Research Group, University of Alicante, Alicante, Spain
| | - Alfonso Marquina Marquez
- Faculty of Education and Social Work, University of Valladolid, Valladolid, Spain.,GIESA, Applied Sociocultural Studies (SEJ208), University of Granada, Granada, Spain
| | | | - Antonio Matas Hoces
- Andalusian School of Public Health (Spanish acronym EASP), Granada, Spain.,Centro Andaluz de Información del Medicamento (CADIME), Campus Universitario de Cartuja, Granada, Spain
| | - Clara Bermúdez Tamayo
- Andalusian School of Public Health (Spanish acronym EASP), Granada, Spain.,Instituto de Investigación Biosanitaria ibs, GRANADA, Granada, Spain.,CIBER en Epidemiología and Salud Pública (CIBERESP), Madrid, Spain
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67
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Neville HL, Losier M, Pitman J, Gehrig M, Isenor JE, Minard LV, Penny E, Bowles SK. Point Prevalence Survey of Benzodiazepine and Sedative-Hypnotic Drug Use in Hospitalized Adult Patients. Can J Hosp Pharm 2020; 73:193-201. [PMID: 32616945 PMCID: PMC7308153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Benzodiazepines and sedative-hypnotic drugs (BZD/SHDs), such as zopiclone and the antidepressant trazodone, pose risks such as falls, fractures, and confusion, especially for older adults. Use of these drugs in the acute care setting is poorly understood. OBJECTIVES To determine the point prevalence and characteristics of use of BZD/SHDs in hospitals in Nova Scotia, Canada. METHODS A point prevalence survey was conducted for adults admitted to all hospitals with at least 30 acute care beds between May and August 2016. Drugs administered intravenously, patients in long-term care, and patients receiving mental health services, addiction treatment, or critical care were excluded. The proportion of included patients who had received a BZD/SHD within the 24 h before the start of the survey was determined. A descriptive statistical analysis was performed. RESULTS Overall BZD/SHD prevalence was 34.6% (487/1409) across the 16 eligible hospitals. The average age was 70.3 years, and 150 (30.8%) of the patients were 80 years or older. Among the 585 prescriptions for these patients, commonly used drugs were zopiclone (32.0%), lorazepam (21.9%), and trazodone (21.9%). The most common indications for use were bedtime/daytime sedation (60.0%) and anxiety (12.5%). More than half of the prescriptions (55.7%) had been initiated at home, 37.6% were started in hospital, and the place of initiation was unknown for 6.7%. Benzodiazepines were prescribed more frequently to patients under 65 years than those 80 years or older (41.3% versus 22.2%, p < 0.001) whereas trazodone was more frequently prescribed to the older of these 2 age groups (52.7% versus 14.3%, p < 0.001). CONCLUSIONS BZD/SHDs were frequently used by hospitalized adult patients in Nova Scotia. Trazodone appears to have been substituted for benzodiazepines in the oldest age group. Pharmacists should direct their efforts toward preventing inappropriate initiation of BZD/SHDs in hospital, particularly for elderly patients.
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Affiliation(s)
- Heather L Neville
- , BScPharm, MSc, FCSHP, is with the Nova Scotia Health Authority, Halifax, Nova Scotia
| | - Mia Losier
- , BScPharm, ACPR, was, at the time of this study, with the Nova Scotia Health Authority and the College of Pharmacy, Dalhousie University, Halifax, Nova Scotia. She is now with Horizon Health Network, Saint John, New Brunswick
| | - Jennifer Pitman
- , BScMedSc, BScPharm, ACPR, was, at the time of this study, with the Nova Scotia Health Authority and the College of Pharmacy, Dalhousie University, Halifax, Nova Scotia. She is now with the Vancouver Island Health Authority, Victoria, British Columbia
| | - Melissa Gehrig
- , BSc(Hons), BScPharm, MSc, is with the Nova Scotia Health Authority, Halifax, Nova Scotia
| | - Jennifer E Isenor
- , BScPharm, PharmD, is with the College of Pharmacy, Dalhousie University, Halifax, Nova Scotia
| | - Laura V Minard
- , BSc, BScPharm, ACPR, PhD, is with the Nova Scotia Health Authority, Halifax, Nova Scotia
| | - Ellen Penny
- , BScPharm, PharmD, BCGP, is with the Nova Scotia Health Authority, Sydney, Nova Scotia
| | - Susan K Bowles
- , BScPhm, MSc, PharmD, FCSHP, is with the Nova Scotia Health Authority and the College of Pharmacy, Dalhousie University, Halifax, Nova Scotia
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68
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Carrier H, Cortaredona S, Philipps V, Jacqmin-Gadda H, Tournier M, Verdoux H, Verger P. Long-term risk of hip or forearm fractures in older occasional users of benzodiazepines. Br J Clin Pharmacol 2020; 86:2155-2164. [PMID: 32285959 DOI: 10.1111/bcp.14307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 03/21/2020] [Accepted: 03/24/2020] [Indexed: 01/14/2023] Open
Abstract
AIMS This article sought to study the association between patterns of benzodiazepine (BZD) use and the risk of hip and forearm fractures in people aged 50 and 75 years or more. METHODS In a representative cohort of the French National Health Insurance Fund of individuals aged 50 years or older (n = 106 437), we followed up BZD dispensing (reflecting their patterns of use) and the most frequent fall-related fractures (hip and forearm) for 8 years. We used joint latent class models to simultaneously identify BZD dispensing trajectories and the risk of fractures in the entire cohort and in those 75 years or older). We used a survival model to estimate the adjusted hazard ratios (aHRs) between these trajectories and the risk of fractures. RESULTS In the entire cohort, we identified 5 BZD trajectories: non-users (76.7% of the cohort); occasional users (15.2%); decreasing users (2.6%); late increasing users (3.0%); and early increasing users (2.4%). Compared with non-users, fracture risk was not increased in either occasional users (aHR = 0.99, 95% confidence interval [CI] 0.99-1.00) or in decreasing users (aHR = 0.90, 95% CI 0.74-1.08). It was significantly higher in early increasing users (aHR = 1.86, 95% CI 1.62-2.14) and in late increasing users (aHR = 1.39, 95% CI 1.15-1.60). We observed similar trajectories and risk levels in the people older than 75 years. CONCLUSION Occasional BZD use, which is compatible with current recommendations, was not associated with an excess risk of the most frequent fall-related fractures in people older than 50 or 75 years.
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Affiliation(s)
- Hélène Carrier
- Aix Marseille Univ, IRD, AP-HM, SSA, VITROME, Marseille, France.,IHU-Méditerranée Infection, Marseille, France.,Department of General Practice, Aix-Marseille University, Marseille, France.,ORS Paca, Regional Health Observatory, Provence-Alpes-Côte d'Azur, Marseille, France
| | - Sébastien Cortaredona
- Aix Marseille Univ, IRD, AP-HM, SSA, VITROME, Marseille, France.,IHU-Méditerranée Infection, Marseille, France
| | - Viviane Philipps
- Univ. Bordeaux, Inserm, Bordeaux Population Health, UMR 1219, ISPED, Bordeaux, France
| | - Hélène Jacqmin-Gadda
- Univ. Bordeaux, Inserm, Bordeaux Population Health, UMR 1219, ISPED, Bordeaux, France
| | - Marie Tournier
- Univ. Bordeaux, Inserm, Bordeaux Population Health, UMR 1219, ISPED, Bordeaux, France.,Centre Hospitalier Charles Perrens, Bordeaux, France
| | - Hélène Verdoux
- Univ. Bordeaux, Inserm, Bordeaux Population Health, UMR 1219, ISPED, Bordeaux, France.,Centre Hospitalier Charles Perrens, Bordeaux, France
| | - Pierre Verger
- Aix Marseille Univ, IRD, AP-HM, SSA, VITROME, Marseille, France.,IHU-Méditerranée Infection, Marseille, France.,ORS Paca, Regional Health Observatory, Provence-Alpes-Côte d'Azur, Marseille, France
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Langford AV, Gnjidic D, Lin CWC, Bero L, Penm J, Blyth FM, Schneider CR. Challenges of opioid deprescribing and factors to be considered in the development of opioid deprescribing guidelines: a qualitative analysis. BMJ Qual Saf 2020; 30:133-140. [PMID: 32220937 DOI: 10.1136/bmjqs-2020-010881] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 03/05/2020] [Accepted: 03/12/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Chronic prescription opioid use is a major international public health issue associated with significant harms, including increased risk of hospitalisation, morbidity and death. Guidance for healthcare professionals on when and how to deprescribe or reduce opioids is required. A key step for guideline development for deprescribing pharmacotherapy is to understand the perspectives of stakeholders. The aim of this study was to explore the perspectives of healthcare professional stakeholders on the challenges associated with opioid deprescribing and factors to be considered in the development of opioid deprescribing guidelines. METHODS A qualitative study was undertaken with a purposive sample of healthcare professionals including prescribers, pharmacists and nurses. An initial cohort of participants was identified at the 2018 Australian Deprescribing Network annual meeting and two focus groups were conducted (n=20). Individual interviews were conducted with a further 11 healthcare professionals. Focus groups and interviews were audio-recorded and transcribed verbatim. Data underwent inductive thematic analysis using a phenomenological perspective. RESULTS Healthcare professionals viewed opioid deprescribing as a challenge and identified several key barriers to deprescribing in clinical practice. Medication, patient, prescriber and health system level challenges were identified. Participants requested evidence-based guidance on the withdrawal of opioid therapies and suggested that prospective opioid deprescribing guidelines require a multitarget, multimodal intervention strategy that addresses patient psychosocial factors and incorporates behavioural change techniques. CONCLUSION Opioid deprescribing was perceived as a complex and challenging practice with continued prescribing the default behaviour. Evidence-based opioid deprescribing guidelines may be a valuable resource for clinicians to support clinical decision-making and reduce suboptimal opioid use.
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Affiliation(s)
- Aili V Langford
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, New South Wales, Australia
| | - Danijela Gnjidic
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, New South Wales, Australia
| | - Chung-Wei Christine Lin
- Institute for Musculoskeletal Health, Faculty of Medicine and Health, School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Lisa Bero
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, New South Wales, Australia.,Charles Perkins Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Jonathan Penm
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, New South Wales, Australia
| | - Fiona M Blyth
- Faculty of Medicine and Health, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Carl R Schneider
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, New South Wales, Australia
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Arriagada L, Carrasco T, Araya M. Polifarmacia y deprescripción en personas mayores. REVISTA MÉDICA CLÍNICA LAS CONDES 2020. [DOI: 10.1016/j.rmclc.2020.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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71
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Sawan M, Reeve E, Turner J, Todd A, Steinman MA, Petrovic M, Gnjidic D. A systems approach to identifying the challenges of implementing deprescribing in older adults across different health-care settings and countries: a narrative review. Expert Rev Clin Pharmacol 2020; 13:233-245. [PMID: 32056451 DOI: 10.1080/17512433.2020.1730812] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: There is increasing recognition of the need for deprescribing of inappropriate medications in older adults. However, efforts to encourage implementation of deprescribing in clinical practice have resulted in mixed results across settings and countries.Area covered: Searches were conducted in PubMed, Embase, and Google Scholar in June 2019. Reference lists, citation checking, and personal reference libraries were also utilized. Studies capturing the main challenges of, and opportunities for, implementing deprescribing into clinical practice across selected health-care settings internationally, and international deprescribing-orientated policies were included and summarized in this narrative review.Expert opinion: Deprescribing intervention studies are inherently heterogeneous because of the complexity of interventions employed and often do not reflect the real-world. Further research investigating enhanced implementation of deprescribing into clinical practice and across health-care settings is required. Process evaluations in deprescribing intervention studies are needed to determine the contextual factors that are important to the translation of the interventions in the real-world. Deprescribing interventions may need to be individually tailored to target the unique barriers and opportunities to deprescribing in different clinical settings. Introduction of national policies to encourage deprescribing may be beneficial, but need to be evaluated to determine if there are any unintended consequences.
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Affiliation(s)
- Mouna Sawan
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia.,Departments of Clinical Pharmacology and Aged Care, Kolling Institute of Medical Research, St Leonards, Australia
| | - Emily Reeve
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, Division of Health Sciences, University of South Australia, Adelaide, Australia.,Geriatric Medicine Research, Faculty of Medicine and College of Pharmacy, Dalhousie University and Nova Scotia Health Authority, Halifax, Canada
| | - Justin Turner
- Faculty of Medicine, University of Montreal, Montreal, Canada
| | - Adam Todd
- School of Pharmacy, Faculty of Medical Science, Newcastle University, Newcastle upon Tyne, UK
| | - Michael A Steinman
- Division of Geriatrics, University of California, San Francisco and the San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Mirko Petrovic
- Section of Geriatrics, Department of Internal Medicine and Paediatrics, Ghent University, Ghent, Belgium
| | - Danijela Gnjidic
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia.,Charles Perkins Centre, The University of Sydney, Camperdown, Australia
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72
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Platt L, Savage TA, Rajagopal N. An Intervention to Decrease Benzodiazepine Prescribing by Providers in an Urban Clinic. J Psychosoc Nurs Ment Health Serv 2020; 58:39-45. [DOI: 10.3928/02793695-20191218-08] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 09/23/2019] [Indexed: 11/20/2022]
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73
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Blanco JR, Morillo R, Abril V, Escobar I, Bernal E, Folguera C, Brañas F, Gimeno M, Ibarra O, Iribarren JA, Lázaro A, Mariño A, Martín MT, Martinez E, Ortega L, Olalla J, Robustillo A, Sanchez-Conde M, Rodriguez MA, de la Torre J, Sanchez-Rubio J, Tuset M. Deprescribing of non-antiretroviral therapy in HIV-infected patients. Eur J Clin Pharmacol 2019; 76:305-318. [PMID: 31865412 DOI: 10.1007/s00228-019-02785-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 10/18/2019] [Indexed: 12/16/2022]
Abstract
PURPOSE In recent decades, the life expectancy of HIV-infected patients has increased considerably, to the extent that the disease can now be considered chronic. In this context of progressive aging, HIV-infected persons have a greater prevalence of comorbid conditions. Consequently, they usually take more non-antiretroviral drugs, and their drug therapy are more complex. This supposes a greater risk of drug interactions, of hospitalization, falls, and death. In the last years, deprescribing has gained attention as a means to rationalize medication use. METHODS Review of the different therapeutic approach that includes optimization of polypharmacy and control and reduction of potentially inappropriate prescription. RESULTS There are several protocols for systematizing the deprescribing process. The most widely used tool is the Medication Regimen Complexity Index, an index validated in HIV-infected persons. Anticholinergic medications are the agents that have been most associated with major adverse effects so, various scales have been employed to measure it. Other tools should be employed to detect and prevent the use of potentially inappropriate drugs. Prioritization of candidates should be based, among others, on drugs that should always be avoided and drugs with no justified indication. CONCLUSIONS The deprescribing process shared by professionals and patients definitively would improve management of treatment in this population. Because polypharmacy in HIV-infected patients show that a considerable percentage of patients could be candidates for deprescribing, we must understand the importance of deprescribing and that HIV-infected persons should be a priority group. This process would be highly feasible and effective in HIV-infected persons.
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Affiliation(s)
- José-Ramón Blanco
- Hospital Universitario San Pedro - CIBIR de Logroño, Logroño, La Rioja, Spain.
| | | | - Vicente Abril
- Hospital General Universitario de Valencia, 46014, València, Valencia, Spain
| | - Ismael Escobar
- Hospital Infanta Leonor del Madrid, Universidad Complutense, 28040, Madrid, Spain
| | - Enrique Bernal
- Hospital General Universitario Reina Sofía de Murcia, 30003, Murcia, Spain
| | - Carlos Folguera
- Hospital Puerta de Hierro de Madrid, 28222, Majadahonda, Madrid, Spain
| | - Fátima Brañas
- Hospital Infanta Leonor del Madrid, Universidad Complutense, 28040, Madrid, Spain
| | | | - Olatz Ibarra
- Hospital de Urduliz, Bizkaia, 48610, Urduliz, Biscay, Spain
| | - José-Antonio Iribarren
- Hospital Universitario Donostia, Instituto BioDonostia de San Sebastián, 20014, San Sebastián, Spain
| | | | - Ana Mariño
- Complejo Hospitalario Universitario de Ferrol, 15405, Ferrol, A Coruña, Spain
| | | | | | | | - Julian Olalla
- Hospital Costa del Sol de Marbella, 29603, Marbella, Málaga, Spain
| | | | | | | | | | | | - Montse Tuset
- Hospital Clinic de Barcelona, 08036, Barcelona, Spain
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74
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Psychosocial intervention for discontinuing benzodiazepine hypnotics in patients with chronic insomnia: A systematic review and meta-analysis. Sleep Med Rev 2019; 48:101214. [DOI: 10.1016/j.smrv.2019.101214] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 09/04/2019] [Accepted: 09/09/2019] [Indexed: 12/22/2022]
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75
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Komagamine J, Yabuki T, Kobayashi M. Association between potentially inappropriate medications at discharge and unplanned readmissions among hospitalised elderly patients at a single centre in Japan: a prospective observational study. BMJ Open 2019; 9:e032574. [PMID: 31699748 PMCID: PMC6858212 DOI: 10.1136/bmjopen-2019-032574] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To determine the prevalence of potentially inappropriate medication (PIM) use at admission and discharge among hospitalised elderly patients and evaluate the association between PIMs at discharge and unplanned readmission in Japan. DESIGN A prospective observational study conducted by using electronic medical records. PARTICIPANTS All consecutive patients aged 65 years or older who were admitted to the internal medicine ward were included. Patients who were electively admitted for diagnostic procedures were excluded. MAIN OUTCOME MEASURES The primary outcome was 30-day unplanned readmissions. The secondary outcome was the prevalence of any PIM use at admission and discharge. PIMs were defined based on the Beers Criteria. The association between any PIM use at discharge and the primary outcome was evaluated by using logistic regression. RESULTS Seven hundred thirty-nine eligible patients were included in this study. The median patient age was 82 years (IQR 74-88); 389 (52.6%) were women, and the median Charlson Comorbidity Index was 2 (IQR 0-3). The proportions of patients taking any PIMs at admission and discharge were 47.2% and 32.2%, respectively. Of all the patients, 39 (5.3%) were readmitted within 30 days after discharge for the index hospitalisation. The use of PIMs at discharge was not associated with an increased risk of 30-day readmission (OR 0.93; 95% CI 0.46 to 1.87). This result did not change after adjusting for patient age, sex, number of medications, duration of hospital stay and comorbidities (OR 0.78; 95% CI 0.36 to 1.66). CONCLUSION The prevalence of any PIM use at discharge was high among hospitalised elderly patients in a Japanese hospital. Although the use of PIMs at discharge was not associated with an increased risk of unplanned readmission, given a lack of power of this study due to a low event rate, further studies investigating this association are needed. TRIAL REGISTRATION NUMBER UMIN000027189.
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Affiliation(s)
- Junpei Komagamine
- Internal Medicine, National Hospital Organization Tochigi Medical Center, Utsunomiya, Japan
| | - Taku Yabuki
- Internal Medicine, National Hospital Organization Tochigi Medical Center, Utsunomiya, Japan
| | - Masaki Kobayashi
- Internal Medicine, National Hospital Organization Tochigi Medical Center, Utsunomiya, Japan
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Abstract
Purpose of Review To evaluate and summarize recent research articles pertaining to insomnia in older adults that can guide healthcare providers on factors to consider when assessing and managing insomnia. Recent Findings Up to 75% of older adults experience symptoms of insomnia. Insomnia is associated with socioeconomic status, racial and ethnic classification, family relationships, medical and mental health disorders, cognitive function, and dementia. Although one-fifth of older adults are still prescribed sleep medications, cognitive behavioral therapy for insomnia is the first line treatment for insomnia, resulting in short-term and long-term benefits. Summary To manage insomnia safely and effectively, healthcare providers need to consistently assess for insomnia during baseline and annual assessments, evaluate medical and social factors associated with insomnia, minimize the use of sleep medications, and provide referrals to and/or collaborate with providers who perform cognitive behavioral therapy for insomnia. Insomnia screening is important as it facilitates early intervention with behavioral management, reduces the potential for pharmacological management, which increases fall risk in older adults, and enables further assessment and early identification of outcomes such as cognitive impairment.
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77
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Outpatient benzodiazepine utilization in Croatia: drug use or misuse. Int J Clin Pharm 2019; 41:1526-1535. [DOI: 10.1007/s11096-019-00915-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 09/19/2019] [Indexed: 11/30/2022]
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78
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Ena J. Reducción del número de prescripciones inadecuadas: comunicación farmacia-prescriptor. Rev Clin Esp 2019; 219:401-402. [DOI: 10.1016/j.rce.2019.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 03/07/2019] [Indexed: 11/28/2022]
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79
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Ena J. Reduction in the number of inadequate prescriptions: Pharmacy-prescriber communication. Rev Clin Esp 2019. [DOI: 10.1016/j.rceng.2019.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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80
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Blanco-Reina E, Valdellós J, Aguilar-Cano L, García-Merino MR, Ocaña-Riola R, Ariza-Zafra G, Bellido-Estévez I. 2015 Beers Criteria and STOPP v2 for detecting potentially inappropriate medication in community-dwelling older people: prevalence, profile, and risk factors. Eur J Clin Pharmacol 2019; 75:1459-1466. [PMID: 31338540 DOI: 10.1007/s00228-019-02722-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Accepted: 07/11/2019] [Indexed: 12/12/2022]
Abstract
PURPOSE To comparatively assess the prevalence rates of potentially inappropriate medications (PIMs) obtained by the former and latest versions of American Geriatrics Society Beers Criteria (AGS BC) and screening tool of older person's potentially inappropriate prescriptions (STOPP), and analyze the factors of influence on PIM. METHODS Cross-sectional study including 582 community-dwelling older adults over the age of 65. Sociodemographic, clinical, functional, and comprehensive drug therapy data were collected. The primary endpoint was the percentage of patients receiving at least one PIM. RESULTS A total of 3626 prescriptions were analyzed. PIMs were detected in 35.4% and 47.9% of patients according to the STOPP v1 and the 2012 AGS BC, respectively. This percentage rose to 54% when 2015 AGS BC were used and reached 66.8% with STOPP v2. The kappa coefficient between STOPP v2 and its former version was lower than the one between the updated Beers Criteria and their former version (0.41 vs 0.85). The agreement was good (0.65) between both latest criteria. The number of medications, psychological disorders, and insomnia were predictors of PIM. A novel finding was that bone and joint disorders increased the odds for PIM by 78%. CONCLUSIONS The 2015 AGS BC showed high sensitivity and good applicability to the European older patients. Both updated tools identified some pharmacological groups (benzodiazepines, PPIs, and opioids, among others) and certain health problems (insomnia, psychological disorders, and osteoarticular diseases) as factors of influence on PIM. Based on these findings, interventions aimed at promoting appropriate use of medications should be developed.
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Affiliation(s)
- Encarnación Blanco-Reina
- Pharmacology and Therapeutics Department, School of Medicine, Instituto de Investigación Biomédica de Málaga-IBIMA, University of Málaga, Campus de Teatinos, Boulevard Louis Pasteur, 32, 29071, Málaga, Spain.
| | | | | | | | | | - Gabriel Ariza-Zafra
- Geriatrics Department, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Inmaculada Bellido-Estévez
- Pharmacology and Therapeutics Department, School of Medicine, Instituto de Investigación Biomédica de Málaga-IBIMA, University of Málaga, Campus de Teatinos, Boulevard Louis Pasteur, 32, 29071, Málaga, Spain
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81
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Nejadshafiee V, Naeimi H, Islami MR. Sonochemical synthesis of library benzodiazepines using highly efficient molecular ionic liquid supported on Fe‐MCM‐41 nanocomposites as a recyclable catalyst. Appl Organomet Chem 2019. [DOI: 10.1002/aoc.5072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Vajihe Nejadshafiee
- Department of Organic Chemistry, Faculty of ChemistryUniversity of Kashan Kashan 87317 I.R. Iran
- Chemistry DepartmentShahid Bahonar University of Kerman Kerman 76169 I.R. Iran
| | - Hossein Naeimi
- Department of Organic Chemistry, Faculty of ChemistryUniversity of Kashan Kashan 87317 I.R. Iran
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82
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Greiver M, Dahrouge S, O’Brien P, Manca D, Lussier MT, Wang J, Burge F, Grandy M, Singer A, Twohig M, Moineddin R, Kalia S, Aliarzadeh B, Ivers N, Garies S, Turner JP, Farrell B. Improving care for elderly patients living with polypharmacy: protocol for a pragmatic cluster randomized trial in community-based primary care practices in Canada. Implement Sci 2019; 14:55. [PMID: 31171011 PMCID: PMC6551894 DOI: 10.1186/s13012-019-0904-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 05/13/2019] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Elders living with polypharmacy may be taking medications that do not benefit them. Polypharmacy can be associated with elevated risks of poor health, reduced quality of life, high care costs, and persistently complex care needs. While many medications could be problematic, this project targets medications that should be deprescribed for most elders and for which guidelines and evidence-based deprescribing tools are available. These are termed potentially inappropriate prescriptions (PIPs) and are as follows: proton pump inhibitors, benzodiazepines, antipsychotics, and sulfonylureas. Implementation strategies for deprescribing PIPs in complex older patient populations are needed. METHODS This will be a pragmatic cluster randomized controlled trial in community-based primary care practices across Canada. Eligible practices provide comprehensive primary care and have at least one physician that consents to participate. Community-dwelling patients aged 65 years and older with ten or more unique medication prescriptions in the past year will be included. The objective is to assess whether the intervention reduces targeted PIPs for these patients compared with usual care. The intervention, Structured Process Informed by Data, Evidence and Research (SPIDER), is a collaboration between quality improvement (QI) and research programs. Primary care teams will form interprofessional Learning Collaboratives and work with QI coaches to review electronic medical record data provided by their regional Practice Based Research Networks (PBRNs), identify areas of improvement, and develop and implement changes. The study will be tested for feasibility in three PBRNs (Toronto, Montreal, and Edmonton) using prospective single-arm mixed methods. Findings will then guide a pragmatic cluster randomized controlled trial in five PBRNs (Calgary, Winnipeg, Ottawa, Montreal, and Halifax). Seven practices per PBRN will be recruited for each arm. The analysis will be by intention to treat. Ten percent of patients who have at least one PIP at baseline will be randomly selected to participate in the assessment of patient experience and self-reported outcomes. Qualitative methods will be used to explore patient and physician experience and evaluate SPIDER's processes. CONCLUSION We are testing SPIDER in a primary care population with complex care needs. This could provide a widely applicable model for care improvement. TRIAL REGISTRATION Clinicaltrials.gov NCT03689049 ; registered September 28, 2018.
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Affiliation(s)
- M. Greiver
- North York General Hospital, 4001 Leslie Street, LE-140, Toronto, Ontario M2K 1E1 Canada
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, 4001 Leslie Street, LE-140, Toronto, Ontario M2K 1E1 Canada
| | - S. Dahrouge
- Department of Family Medicine, University of Ottawa, 85 Primrose Avenue, Ottawa, Ontario K1R 6M1 Canada
- Bruyère Research Institute, 43 Bruyère Street, Ottawa, Ontario K1N 5C8 Canada
| | - P. O’Brien
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, 4001 Leslie Street, LE-140, Toronto, Ontario M2K 1E1 Canada
| | - D. Manca
- Department of Family Medicine, University of Alberta, 8303 - 112 Street NW, 610 University Terrace, Edmonton, Alberta T6G 2T4 Canada
| | - M. T. Lussier
- Department of Family Medicine and Emergency Medicine, University of Montreal, 1755 René Laennec, Bureau DS-079, Laval, Québec H7M3L9 Canada
| | - J. Wang
- North York General Hospital, 4001 Leslie Street, LE-140, Toronto, Ontario M2K 1E1 Canada
| | - F. Burge
- Department of Family Medicine, Dalhousie University, 8F, 8525 Abbie J Lane Building, 5909 Veterans’ Memorial Lane, Halifax, Nova Scotia B3H 2E2 Canada
| | - M. Grandy
- Department of Family Medicine, Dalhousie University, 8F, 8525 Abbie J Lane Building, 5909 Veterans’ Memorial Lane, Halifax, Nova Scotia B3H 2E2 Canada
| | - A. Singer
- Department of Family Medicine, University of Manitoba, D009 – 780 Bannatyne Ave, Winnipeg, Manitoba R3T 2N2 Canada
| | - M. Twohig
- North York General Hospital, 4001 Leslie Street, LE-140, Toronto, Ontario M2K 1E1 Canada
| | - R. Moineddin
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, 4001 Leslie Street, LE-140, Toronto, Ontario M2K 1E1 Canada
- ICES, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, 500 University Avenue, Toronto, Ontario M5G 1V7 Canada
| | - S. Kalia
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, 4001 Leslie Street, LE-140, Toronto, Ontario M2K 1E1 Canada
| | - B. Aliarzadeh
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, 4001 Leslie Street, LE-140, Toronto, Ontario M2K 1E1 Canada
| | - N. Ivers
- Family Practice Health Centre and Women’s College Research Institute, Women’s College Hospital, 76 Grenville Street, Toronto, Ontario M5S 1B2 Canada
| | - S. Garies
- Department of family Medicine, Cumming School of Medicine, University of Calgary, G012 Health Sciences Centre, 3330 Hospital Drive NW, Calgary, Alberta T2N 4N1 Canada
| | - J. P. Turner
- Faculty of Pharmacy, University of Montreal, 2900 Edouard Montpetit Boulevard, Montreal, Quebec H3T 1J4 Canada
- Centre de Recherche, Institut Universitaire de Geriatrie de Montreal, Montreal, Canada
| | - B. Farrell
- Department of Family Medicine, University of Ottawa, 85 Primrose Avenue, Ottawa, Ontario K1R 6M1 Canada
- Bruyère Research Institute, 43 Bruyère Street, Ottawa, Ontario K1N 5C8 Canada
- School of Pharmacy, University of Waterloo, Waterloo, Canada
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83
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Karttunen N, Taipale H, Hamina A, Tanskanen A, Tiihonen J, Tolppanen AM, Hartikainen S. Concomitant use of benzodiazepines and opioids in community-dwelling older people with or without Alzheimer's disease-A nationwide register-based study in Finland. Int J Geriatr Psychiatry 2019; 34:280-288. [PMID: 30370943 DOI: 10.1002/gps.5018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 10/18/2018] [Indexed: 11/10/2022]
Abstract
OBJECTIVE The study aims to determine the prevalence of concomitant use of benzodiazepines and opioids among community-dwelling older people with or without Alzheimer's disease (AD). An additional aim was to describe the factors associated with prolonged concomitant use, and the most commonly used combinations of these drugs. METHODS This study utilized data from the register-based Medication Use and Alzheimer's disease (MEDALZ) study, including all community-dwelling residents of Finland who received a clinically verified AD diagnosis between 2005 and 2011 (n = 70 718) and their matched comparison persons without AD. After exclusion of individuals who were hospitalized throughout the follow-up, 69 353 persons with and 69 353 without AD were included in this study. RESULTS Benzodiazepines and related drugs (BZDRs) were used by 28 475 (41.1%) of those with and 24 506 (35.3%) of those without AD. Prolonged (greater than or equal to 90 days) concomitant use of BZDRs and opioids was more common among BZDR users without AD (N = 3936; 16.1%) than among those with AD (N = 2963; 10.4%). A shorter duration of concomitant use (1-89 days) revealed similar results, N = 3821; 15.6% and N = 3008; 10.6%, respectively. Prolonged concomitant use of BZDRs and opioids was associated with female sex, low socioeconomic position, most of the common comorbidities and history of substance abuse or long-term benzodiazepine use. The most commonly used combinations were Z-drug (31.7%) or benzodiazepine (29.9%) with a weak opioid. CONCLUSIONS Despite the recommendations and risks, the prevalence of concomitant BZDR and opioid use was common in older persons with or without AD. It is important to develop strategies to reduce unnecessary concomitant use of these drugs.
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Affiliation(s)
- Niina Karttunen
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland.,School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Heidi Taipale
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland.,School of Pharmacy, University of Eastern Finland, Kuopio, Finland.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Aleksi Hamina
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland.,School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Antti Tanskanen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland.,Impact Assessment Unit, National Institute for Health and Welfare, Helsinki, Finland
| | - Jari Tiihonen
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland.,Center for Psychiatry Research, Stockholm City Council, Stockholm, Sweden
| | - Anna-Maija Tolppanen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland.,Research Centre for Comparative Effectiveness and Patient Safety (RECEPS), University of Eastern Finland, Kuopio, Finland
| | - Sirpa Hartikainen
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland.,School of Pharmacy, University of Eastern Finland, Kuopio, Finland.,Research Centre for Comparative Effectiveness and Patient Safety (RECEPS), University of Eastern Finland, Kuopio, Finland
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84
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Prescriber Implementation of STOPP/START Recommendations for Hospitalised Older Adults: A Comparison of a Pharmacist Approach and a Physician Approach. Drugs Aging 2019; 36:279-288. [DOI: 10.1007/s40266-018-0627-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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85
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Gnjidic D, Ong HMM, Leung C, Jansen J, Reeve E. The impact of in hospital patient-education intervention on older people's attitudes and intention to have their benzodiazepines deprescribed: a feasibility study. Ther Adv Drug Saf 2019; 10:2042098618816562. [PMID: 30728943 PMCID: PMC6351969 DOI: 10.1177/2042098618816562] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background Long-term benzodiazepine use in the older population is common and is associated with significant harm. The provision of a patient-educational booklet during hospitalization may encourage patients to discuss review and possible deprescribing of benzodiazepine therapy with their health professionals. The aim of this study was to assess the feasibility and effect of a patient empowerment intervention in hospital inpatients on patient initiation of a discussion about deprescribing benzodiazepines versus usual care. Methods A feasibility interventional study using a patient-empowerment education intervention was conducted at a Sydney teaching hospital. Patients aged ⩾ 65 years, prescribed a benzodiazepine, and able to provide consent were invited to participate in the study. Participants were randomly allocated to intervention or control group (1:1). Intervention participants received the patient-empowerment booklet and control received usual care. All participants received 1-month follow-up phone interviews to assess medication and attitudinal changes. Results A total of 42 participants were recruited (20 intervention and 22 control). The average age was 71.5 (interquartile range: 69.0-80.3) and 54.8% were females. There was no difference in baseline characteristics between intervention and control groups (p > 0.05). At baseline, 65.0% of participants (53.0% intervention, 86.0% control) were not concerned about the potential benzodiazepine side effects. Twenty-nine participants (15 intervention and 14 control) completed 1-month follow up; 22 participants (11 intervention and 11 control) were discharged on the benzodiazepine. Among these, 13 (59.1%) had ceased benzodiazepine at 1-month follow up [46.2% (n = 6) intervention; 53.8% (n = 7) control]. In the intervention group, 33.3% (n = 5) of participants had initiated a discussion with their doctor or pharmacist about stopping the benzodiazepine compared with 35.7% (n = 5) in the control group. Conclusion Cessation of benzodiazepines 1 month following discharge was common. Future larger studies are required to confirm the effectiveness of providing a patient-empowerment booklet on reducing benzodiazepine use and other potentially inappropriate medications.
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Affiliation(s)
| | | | | | - Jesse Jansen
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Emily Reeve
- Faculty of Medicine and Health, University of Sydney, NSW, Australia Geriatric Medicine Research, Dalhousie University and Nova Scotia Health Authority, NS, Canada College of Pharmacy, Dalhousie University, NS, Canada
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86
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Abstract
Intrathecal baclofen therapy is a well-established technique for spasticity management. This article briefly reviews the pharmacology of intrathecal baclofen as well as customary approach for utilization of this targeted drug delivery concept. Following these descriptions, four unusual presentations will be described, including the need for initial trialing, patient-directed boluses during chronic intrathecal baclofen therapy, use of medications other than baclofen for intrathecal therapy in spastic patients, and intraventricular baclofen delivery. These hypothetical cases are provided in an effort to expand the use of targeted drug delivery to larger population of spastic patients.
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Affiliation(s)
- Michael Saulino
- MossRehab, 60 Township Line Road, Elkins Park, PA 19027, USA; Department of Rehabilitation Medicine, Thomas Jefferson University, Philadelphia, PA, USA.
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87
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Approaches to Deprescribing Psychotropic Medications for Changed Behaviours in Long-Term Care Residents Living with Dementia. Drugs Aging 2018; 36:125-136. [DOI: 10.1007/s40266-018-0623-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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88
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Lähteenmäki R, Neuvonen PJ, Puustinen J, Vahlberg T, Partinen M, Räihä I, Kivelä S. Withdrawal from long‐term use of zopiclone, zolpidem and temazepam may improve perceived sleep and quality of life in older adults with primary insomnia. Basic Clin Pharmacol Toxicol 2018; 124:330-340. [DOI: 10.1111/bcpt.13144] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 09/24/2018] [Indexed: 12/01/2022]
Affiliation(s)
| | - Pertti J. Neuvonen
- Department of Clinical Pharmacology University of Helsinki, and HUSLAB Helsinki University Hospital Helsinki Finland
| | - Juha Puustinen
- Unit of Neurology Satakunta Hospital District Pori Finland
- Division of Pharmacology and Pharmacotherapy Clinical Pharmacy Group University of Helsinki Helsinki Finland
| | - Tero Vahlberg
- Department of Biostatistics University of Turku Turku Finland
| | - Markku Partinen
- Helsinki Sleep Clinic Vitalmed Research Center Helsinki Finland
- Department of Neurology University of Helsinki Helsinki Finland
| | - Ismo Räihä
- Department of Family Medicine University of Turku Turku Finland
| | - Sirkka‐Liisa Kivelä
- Department of Family Medicine University of Turku Turku Finland
- Division of Pharmacology and Pharmacotherapy Clinical Pharmacy Group University of Helsinki Helsinki Finland
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89
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Take a multifaceted stepwise approach when deprescribing benzodiazepines in older patients. DRUGS & THERAPY PERSPECTIVES 2018. [DOI: 10.1007/s40267-018-0578-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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90
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Madrid González M, Guerro de Prado M. Pulseras de actividad como ayuda a la deprescripción de hipnóticos. Semergen 2018; 44:512-514. [DOI: 10.1016/j.semerg.2018.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 02/03/2018] [Accepted: 03/01/2018] [Indexed: 11/16/2022]
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91
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Hilmer SN, Gnjidic D. Deprescribing: the emerging evidence for and the practice of the 'geriatrician's salute'. Age Ageing 2018; 47:638-640. [PMID: 30165501 DOI: 10.1093/ageing/afy014] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Indexed: 12/29/2022] Open
Abstract
The process of a health professional withdrawing medicines for which the current risk may outweigh the benefit in the individual patient has been given a variety of names including the colloquial 'geriatrician's salute', 'de-intensification' and increasingly 'deprescribing'. The rise of deprescribing as a word with a definition, evidence base and implementation plan, reflects the changing environment in which we practice. In particular, the emphasis on evidence-based medicine and the need to care for our expanding ageing populations, which requires application of components of geriatric evaluation and management by a wider range of health care practitioners. However, there are still significant challenges related to research on the safety, efficacy and implementation of deprescribing. In this commentary, we discuss the current evidence on the effects of deprescribing, emergence of implementation tools to embed deprescribing into the clinical care of older adults, as well as efforts to develop guidelines to improve health care practitioners' awareness and self-efficacy of deprescribing. Ultimately, judicious prescribing and deprescribing, across a wide range of health care settings, ought to enable older people to use medicines to support their achievable ageing goals.
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Affiliation(s)
- Sarah N Hilmer
- Kolling Institute of Medical Research, Sydney Medical School, Sydney University and Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Danijela Gnjidic
- Faculty of Pharmacy and Charles Perkins Centre, University of Sydney, New South Wales, Australia
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92
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Kalisch Ellett LM, Lim R, Pratt NL, Kerr M, Ramsay EN, LeBlanc TV, Barratt JD, Roughead EE. Reducing hypnotic use in insomnia management among Australian veterans: results from repeated national interventions. BMC Health Serv Res 2018; 18:626. [PMID: 30092801 PMCID: PMC6085677 DOI: 10.1186/s12913-018-3443-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 08/02/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Australian Government Department of Veterans' Affairs (DVA) Veterans' Medicines Advice and Therapeutics Education Services (Veterans' MATES) programme conducted two intervention (March 2009, follow-up intervention June 2012) both of which aimed to reduce hypnotic use among Australian veterans. We evaluated the effectiveness of the interventions, and estimated the associated health consequences. METHODS Both interventions targeted veterans who had been dispensed hypnotics prior to the intervention. Patient-specific prescriber feedback containing patient details and the volume of hypnotics dispensed, along with tailored educational information, was mailed to general practitioners. Veterans, pharmacists and directors of care in residential aged care facilities were mailed tailored educational information. Interrupted time-series and segmented regression modelling were used to determine the effect of the two interventions on the rate of hypnotics dispensing. The cumulative patient-months of hypnotic treatment avoided as a result of the interventions was calculated. We estimated improvements in health consequences of as a result of hypnotic treatment avoided based on the results of cohort studies in the same population identifying the association between hypnotic and sedative use on the outcomes of falls, and confusion. RESULTS After the first Veterans' MATES intervention in March 2009, hypnotic use declined by 0.2% each month, when compared to the baseline level (p = 0.006). The intervention effect was attenuated after one year, and use of hypnotics was found to increase by 0.2% per month after March 2010. Following the second intervention in June 2012, there was a further significant decline in use of 0.18% each month over the 12 months of follow up (p = 0.049). The cumulative effect of both interventions resulted in 20,850 fewer patient-months of treatment with hypnotics. This cumulative reduction in hypnotic use was estimated to lead to a minimum of 1 fewer hospital admissions for acute confusion and 7 fewer hospital admissions due to falls. CONCLUSIONS The Veterans' MATES insomnia interventions which involved multiple stakeholders were effective in reducing hypnotic use among older Australians. Repetition of key messages led to sustained practice change.
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Affiliation(s)
- Lisa M. Kalisch Ellett
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide, South Australia 5001 Australia
| | - Renly Lim
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide, South Australia 5001 Australia
| | - Nicole L. Pratt
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide, South Australia 5001 Australia
| | - Mhairi Kerr
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide, South Australia 5001 Australia
| | - Emmae N. Ramsay
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide, South Australia 5001 Australia
| | - Tammy V. LeBlanc
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide, South Australia 5001 Australia
| | - John D. Barratt
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide, South Australia 5001 Australia
| | - Elizabeth E. Roughead
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide, South Australia 5001 Australia
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93
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Deprescribing Benzodiazepines in Older Patients: Impact of Interventions Targeting Physicians, Pharmacists, and Patients. Drugs Aging 2018; 35:493-521. [PMID: 29705831 DOI: 10.1007/s40266-018-0544-4] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Benzodiazepines (BZDs; including the related Z-drugs) are frequently targets for deprescribing; long-term use in older people is harmful and often not beneficial. BZDs can result in significant harms, including falls, fractures, cognitive impairment, car crashes and a significant financial and legal burden to society. Deprescribing BZDs is problematic due to a complex interaction of drug, patient, physician and systematic barriers, including concern about a potentially distressing but rarely fatal withdrawal syndrome. Multiple studies have trialled interventions to deprescribe BZDs in older people and are discussed in this narrative review. Reported success rates of deprescribing BZD interventions range between 27 and 80%, and this variability can be attributed to heterogeneity of methodological approaches and limited generalisability to cognitively impaired patients. Interventions targeting the patient and/or carer include raising awareness (direct-to-consumer education, minimal interventions, and 'one-off' geriatrician counselling) and resourcing the patient (gradual dose reduction [GDR] with or without cognitive behavioural therapy, teaching relaxation techniques, and sleep hygiene). These are effective if the patient is motivated to cease and is not significantly cognitively impaired. Interventions targeted to physicians include prescribing interventions by audit, algorithm or medication review, and providing supervised GDR in combination with medication substitution. Pharmacists have less frequently been the targets for studies, but have key roles in several multifaceted interventions. Interventions are evaluated according to the Behaviour Change Wheel. Research supports trialling a stepwise approach in the cognitively intact older person, but having a low threshold to use less-consultative methods in patients with dementia. Several resources are available to support deprescribing of BZDs in clinical practice, including online protocols.
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Musich S, Wang SS, Slindee LB, Saphire L, Wicker E. Characteristics of New-Onset and Chronic Sleep Medication Users Among Older Adults: A Retrospective Study of a US Medigap Plan Population using Propensity Score Matching. Drugs Aging 2018; 35:467-476. [PMID: 29651640 PMCID: PMC5956055 DOI: 10.1007/s40266-018-0543-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Prescription sleep medications are often utilized to manage sleep problems among older adults even though these drugs are associated with multiple risks. Objective The aim was to determine the prevalence and characteristics of new-onset compared to chronic sleep medication users and to examine factors associated with the conversion from new to chronic use. A secondary objective was to investigate the impact of sleep medications on health outcomes of injurious falls and patterns of healthcare utilization and expenditures. Methods A 25% random sample of adults ≥ 65 years with 3-year continuous AARP® Medicare Supplement medical and AARP® MedicareRx drug plan enrollment was utilized to identify new-onset and chronic sleep medication users. Prescription sleep medication drugs were defined using National Drug Codes (NDCs); falls or hip fractures were identified from diagnosis codes. New users had no sleep medication use in 2014, but initiated medication use in 2015; chronic users had at least one sleep medication prescription in 2014 and in 2015; both groups had follow-up through 2016. Characteristics associated with new users, new users who converted to chronic use, and chronic users were determined using multivariate logistic regression. Prevalence of falls, healthcare utilization and expenditures were regression adjusted. Results Among eligible insureds, 3 and 9% were identified as new-onset and chronic sleep medication users, respectively. New-onset sleep medication prescriptions were often associated with an inpatient hospitalization. The strongest characteristics associated with new users, those who converted to chronic use, and chronic users were sleep disorders, depression and opioid use. About 50% of new users had > 30 days’ supply; 25% converted to chronic use with ≥ 90 days’ supply. The prevalence of falls for new-onset users increased by 70% compared to a 22% increase among chronic users. Conclusion New-onset and chronic sleep medication users were characterized by sleep disorders, depression and pain. Addressing the underlying problems associated with sleep problems among older adults may decrease the need for sleep medications and thus reduce the risk of sleep medication-related adverse events.
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Affiliation(s)
- Shirley Musich
- Research for Aging Populations, Optum, 315 E. Eisenhower Parkway, Suite 305, Ann Arbor, MI 48108 USA
| | - Shaohung S. Wang
- Research for Aging Populations, Optum, 315 E. Eisenhower Parkway, Suite 305, Ann Arbor, MI 48108 USA
| | - Luke B. Slindee
- Informatics and Data Science, Optum, 12700 Whitewater Drive, Minnetonka, MN 55343 USA
| | - Lynn Saphire
- Medicare and Retirement, UnitedHealthcare Alliances, PO Box 9472, Minneapolis, MN 55440 USA
| | - Ellen Wicker
- AARP Services, Inc., 601 E. Street, N.W., Washington, DC 20049 USA
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95
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Del Giorno R, Greco A, Zasa A, Clivio L, Pironi M, Ceschi A, Gabutti L. Combining prescription monitoring, benchmarking, and educational interventions to reduce benzodiazepine prescriptions among internal medicine inpatients; a multicenter before and after study in a network of Swiss Public Hospitals. Postgrad Med 2018; 130:627-636. [DOI: 10.1080/00325481.2018.1504594] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Rosaria Del Giorno
- Department of Internal Medicine and Nephrology, Regional Hospital of Bellinzona and Valli, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Angela Greco
- Quality and Patient Safety Service, La Carità Hospital, Ente Ospedaliero Cantonale, Locarno, Switzerland
| | - Anna Zasa
- Quality and Patient Safety Service, La Carità Hospital, Ente Ospedaliero Cantonale, Locarno, Switzerland
| | - Luca Clivio
- Department of Informatics, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Michela Pironi
- Central Pharmacy Service, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Alessandro Ceschi
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, Zurich, Switzerland
| | - Luca Gabutti
- Department of Internal Medicine and Nephrology, Regional Hospital of Bellinzona and Valli, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Institute of Biomedicine, University of Southern Switzerland, Lugano, Switzerland
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Abstract
In the United States, benzodiazepine medication use is the secondary epidemic to opioid drug use and carries serious consequences as well, even though its use is enabled by well-intended clinicians. Benzodiazepine drugs are intended for short-term use, not to exceed 2 to 4 weeks; yet, it is common for clients to be taking benzodiazepine medications for up to 10 years. In addition to dependence or addiction, adverse effects include depression, emotional blunting, ataxia, aggression, irritability, nervousness, and cognitive impairment. These medications also contribute to increased risk for falls, suicide, overdose fatality, and vehicle crashes. The current article describes the epidemiology of benzodiazepine medication use, patient and prescriber factors that contribute to overuse and misuse, and recommendations for prescribing and deprescribing. [Journal of Psychosocial Nursing and Mental Health Services, 56(6), 11-15.].
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97
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Pruskowski J, Rosielle DA, Pontiff L, Reitschuler-Cross E. Deprescribing and Tapering Benzodiazepines #355. J Palliat Med 2018; 21:1040-1041. [DOI: 10.1089/jpm.2018.0264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Wilson MG, Lee TC, Hass A, Tannenbaum C, McDonald EG. EMPOWERing Hospitalized Older Adults to Deprescribe Sedative Hypnotics: A Pilot Study. J Am Geriatr Soc 2018; 66:1186-1189. [DOI: 10.1111/jgs.15300] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
| | - Todd C. Lee
- Department of Medicine; McGill University; Montréal Quebec Canada
- Clinical Practice Assessment Unit; McGill University Health Centre; Montréal Quebec Canada
| | - Aaron Hass
- Clinical Practice Assessment Unit; McGill University Health Centre; Montréal Quebec Canada
| | - Cara Tannenbaum
- Division of Geriatrics, Department of Medicine; Université de Montréal; Montréal Quebec Canada
| | - Emily G. McDonald
- Department of Medicine; McGill University; Montréal Quebec Canada
- Clinical Practice Assessment Unit; McGill University Health Centre; Montréal Quebec Canada
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Aguiluz J, Álvarez M, Pimentel E, Abarca C, Moore P. How to face a patient with benzodiazepine dependence in primary health care? Strategies for withdrawal. Medwave 2018; 18:e7159. [PMID: 29385122 DOI: 10.5867/medwave.2018.01.7159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Accepted: 01/08/2018] [Indexed: 11/27/2022] Open
Abstract
Benzodiazepines are widely used in primary health care, and their prolonged use is an important problem given the medical consequences particularly in older adults, such as dependence, cognitive impairment, and risk of falls, among others. Primary care doctors generally have few tools to help with managing withdrawal from benzodiazepines. We conducted a review of the best available evidence on practical strategies to avoid dependence at the time of the initial prescription, and to help the patient with prolonged and probably dependent use. We found ten relevant systematic reviews showing evidence in favor of the use of multifaceted prescription strategies, gradual dose reduction, standardized letters, standardized counseling, pharmacotherapy and cognitive behavioral psychotherapy. For benzodiazepine withdrawal, a simple strategy that can be effective and long-lasting is to inform patients of the need to reduce consumption, giving them in writing the withdrawal guideline, indicating the possible effects of withdrawal and its solution. Given the available evidence, an integrated and step-by-step model is proposed for the management of the benzodiazepine user, from prescription to withdrawal.
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Affiliation(s)
- Josefina Aguiluz
- Facultad de Medicina, Pontificia Universidad Católica, Santiago, Chile. Address: Los Almendros 9183, La Florida, Santiago, Chile, CP: 8240000.
| | - Matías Álvarez
- Facultad de Medicina, Pontificia Universidad Católica, Santiago, Chile
| | - Eduardo Pimentel
- Facultad de Medicina, Pontificia Universidad Católica, Santiago, Chile
| | - Carolina Abarca
- Centro de Salud Familiar Áncora San Alberto Hurtado, Puente Alto, Santiago, Chile; Departamento de Medicina Familiar, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Philippa Moore
- Departamento de Medicina Familiar, Pontificia Universidad Católica de Chile, Santiago, Chile
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100
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Clinical and Economic Outcomes of Interventions to Reduce Antipsychotic and Benzodiazepine Use Within Nursing Homes: A Systematic Review. Drugs Aging 2018; 35:123-134. [DOI: 10.1007/s40266-018-0518-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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